Phantom LimbsThe Ramachandran
Method and The NLP Practitioner

All
amputees, and all who work with them, know that a phantom limb is essential
if an artificial limb is to be used. Dr. Michael Kremer writes: "Its
value to the amputee is enormous. I am quite certain that no amputee
with an artificial lower limb can walk on it satisfactorily until the
body-image, in other words, the phantom, is incorporated into it."

Thus the disappearance of a phantom limb may be
disasterous, and its recovery, its reanimation, a matter of urgency.
This may be effected in all sorts of ways: Weir Mitchell describes how,
with faradisation of the brachial plexus, a phantom hand, missing for
twenty-five years, was suddenly resurrected. One such patient, under
my care, describes he must 'wake up' his phantom in the mornings: first
he flexes the thigh-stump towards him, and then he slaps it sharply
- 'like a baby's bottom' - several times. On the fifth or sixth slap
the phantom suddenly shoots forth, rekindled, fulgurated, by the peripheral
stimulus. Only then can he put on his prosthesis and walk. What other
odd methods (one wonders) are used by amputees?

"Phantom limb" pain has been recorded almost as long as people have
been losing limbs and surviving. As we can see on the motor cortex,
specific areas function to map out specific parts of the body. Losing
a part of the body doesn't necessarily stop the cortex from continuing
to "map" the missing part, adding a slight twist to Korzybski`s, "the
map is not the territory."

Whilst it is common to refer to phantom limbs, "phantom"
breasts, penis's, ears and other "phantom" bodily parts have been reported
in patients who have undergone removal of these same parts.

Whilst not all amputees will experience phantom limb pain,
there is evidence to suggest that the majority will at least initially
continue to perceive the body part as still being present in some form.

For example, one patient of mine required a "bed cradle"
prior to amputation to raise the bed linen off her painfully ulcerated
legs continued to require the "bed cradle" for at least a week post
surgery, lest she see the sheets rest upon her phantom ulcerated
leg, causing severe pain.

Previous attempts at eliminating the phantom pains involved
surgery to remove another inch or two from the affected limb/stump or
even cutting through the relevant nerve root emerging from the spinal
cord. These methods are very rarely found to be effective and generally
end up with a surgical "game without end" in a manner described by Ramachandran
as "chasing the phantom."

Patients with this pain will generally refer to the pain
being in the spatial location of where the limb would have been or may
even continue to experience a deterioration of the limb with an accompanied
increase in pain. Curiously, the phantom limb may be painless at first
only to develop pain as the phantom limb begins to develop contractures,
particularly if the limb was paralysed prior to amputation.

As a generalization, there is less likely to be phantom
pain following amputation if the patient is given sufficient analgesia
for a 1-2 week period prior to the surgery. Conversely, the greater
the pain in the period immediately prior to surgery, the greater the
pain is likely to be post surgery.

NLP Case Study. I was called to see a lady on a medical unit who had suffered
a compound fracture of her femur, which has subsequently become grossly
infected resulting in necrosis of the limb and necessitating amputation.
The injury had occurred whilst as an in-patient in a neighboring hospital
for an unrelated problem and two of the nursing staff were held to be
negligent with regards to the incident that precipitated injury. The
unfortunate patient had been transferred to a different hospital whilst
litigation was pursued. The patient held a considerable amount of hostility
towards the staff involved and was devastated by the injury and loss
of her leg. She has also suffered a minor left sided CVA (stroke) secondary
to the fractured femur. By the time of contact, the deficits from the
CVA had mostly resolved. The patient was continuing to require high
doses of morphine for her "phantom limb pain".

Method: The patient was asked to close her eyes
and describe her healthy hand, which was positioned cataleptic in front
of her face. The submodalities were elicited and slight changes in submodalities
were suggested as a preliminary "trial run" to later change work. The
submodalities of a memory from a distant and unpleasant time were elicited
and a submodality swish demonstrated. A representation of a good and
pleasant occasion was elicited and submodalities elicited and "tweaked"
and positive state anchored and reinforced.

Next step, the representation and submodalities
of the healthy limb were elicited and compared to that of the hand,
which remained cataleptic in its initial position in front of her face.
Note that at this point, the session was interrupted by the surgical
team on their "rounds" who made a brief examination of the stump and
exchanged a brief communication with the patient, who replied normally
and to the satisfaction of the surgeons. During this time, the only
evidence of trance was the cataleptic hand which did not move and went
unnoticed by the surgical team.

Elicitation of the "phantom leg" representation
and submodalities provided a shift in state and submodalities were significantly
different. This representation was larger, misshapen, confused and full
of sounds of screaming. The content of the representation reflected
an associated movie of the incident in which the leg was initially fractured.
The revulsion expressed by the patient was the appearance of bone through
her skin and the hitherto unknown detail that the patient had tumbled
from a filled commode and her broken leg had been brought into contact
with said contents. This "movie" formed an unpleasant and endlessly
playing movie loop.

With this turn of events, the patient was associated
into a neutral state and a double dissociation technique used to dissociate
her from the traumatic events. With the representation of this event
de-potentiated, a submodality and content swish pattern was carried
out, swishing the submodalites of the damaged leg for a representation
of how the leg/stump would appear once it had fully healed.

This entire procedure, including time for interruption,
lasted approximately 20 minutes.

The patient reported an 80% reduction in her discomfort.

Ramachandran
describes an ingenious method for reducing phantom limb pains that reflects
his brilliance at working with neurological programming to produce profound
change.

He describes in detail the behaviour of phantom limbs
that might not necessarily hurt, but will gesture, itch, twitch or even
try to pick things up. He also describes that some people's representations
of their limbs don't actually match what they should be, for example,
one patient reported that her phantom arm was about "6 inches too short".

A common feature is that some people with phantom limbs
who find that the limb will gesticulate as they talk. Many people find
that sitting on their hands can seriously impede their ability for verbal
description. Most of us still gesture when speaking to someone on the
telephone. Given the way that the hands and arms are represented on
the motor cortex and language centers, this is not surprising. Whilst
some people find that their phantom limbs feels and behaves as though
it is still there, other find that it begins to take on a life of it's
own, and doesn't obey what they request it to do.

I placed a coffee cup in front of John and asked him
to grab it. Just as he said he was reaching out, I yanked the cup away.
"Ow!" he yelled. "Don't do that!"
"What's the matter?"
"Don't do that," he repeated. "I had just got my fingers around the cup
handle when you pulled it. That really hurts!"
Hold on a minute. I wrench a real cup from phantom fingers and the person
yells, ouch! The fingers were illusory, but the pain was real - indeed,
so intense that I dared not repeat the experiment.

Like the patient with the bed cradle, visual feedback
and expectation appears to play an important role in the phantom limb
phenomena. It is this effect that Ramachandran used when he devised
his feedback machine consisting of a mirror and a cardboard box.

With the healthy arm through the hole corresponding
with the reflective side of the mirror, he maneuvers his phantom arm
through the other hole (be imaginative with this one to help the client
do this). Thus now, the client has a reflection of his real arm that,
with some maneuvering, will correspond exactly with the missing limbs
location. This enables the brain of the person to achieve feedback
to the motor area of the brain corresponding with the phantom:

Philip rotated his body, shifting his shoulder,
to "insert" his lifeless phantom into the box. Then he put his right
hand on the other side of the mirror and attempted to make synchronous
movements. As he gazed into the mirror, he gasped and then cried out,
"Oh, my God! Oh, my God, doctor! This is unbelievable. It's mind boggling!"
He was jumping up and down like a kid. "My left arm is plugged in
again. It's as if I'm in the past. All these memories from so many
years ago are flooding back into my mind. I can move my arm again.
I can feel my elbow moving, my wrist moving. It's all moving again.

Ramachandran asked Philip to close his eyes and Philips
phantom arm once again became lifeless until he once again opened
his eyes.

Curiously, despite the historical referential experiences
that flooded into consciousness, four weeks later following ten minutes
a day with the box and mirror, Philip reported that the limb had gone,
"all I have now is my phantom fingers and palm dangling from my
shoulder." The pains had significantly reduced (only the fingers
still hurt - the rest had gone) and Philip now possessed an altered
but more realistic body "image" mapped onto his sensory cortex:

"It's not clear why his fingers didn't disappear,
but one reason might be that they are over-represented - like the
huge lips on the Penfield map - in the somatosensory cortex and may
be more difficult to deny."